Louisville Fire and Rescue Met1·0 Arson Squad

501 Ashland Avenue Louisville, Kentucky 40214

(S02) 574-3721

Investigation Type: Structure Fire Department/District: Okolona Fire Department

Address: 4000 Buechel Bank Road Building 6 Date: Friday, Apri l 03, 2015 Time: 6:51

Incident Number: 15-80-000597 Census Tract: 110.020

Lead Investigator: Major G. Henry Ott Assisting Investigators: None

Arson Res onse Dispatched :

Arrived:

Cleared:

I Request ing Individual :

I Requesting Company:

L_ __ ~ latoon:

05-Apr-15 7:00:00 AM 7:01

0:00 Chief Gosnell

Okolona FD 2nd Platoon _J

Weather Information Weather Conditions: Raining

Temperature : 60

Wind Direction: Northwest Snow Accumulation:

[_ - - - ----- ___ __,

Synopsis ______________ _ ____ _

FBI Classification: C. Storage Heat Source: Undetermined

/ Material First Ignited: Undetennined , Cause Classification: Undetermined

j Cause: 9 - 00 : Other Ignition Factor - Ignition Factor undetermined or not j L _______ reported ____ ____ _ _ _ _ _ __ _

Conclusion

IAfter an extensive investigation which resulted in the eliminatio; of many causes, a final j !determination could not be made between sometyp e of an electrical failure or a lightnin g I ~ ike._As a result, the caus~ is listed as undetermined as require<!_ by NFP A 921 __ _J

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Incident 15-80-000597 Structure Information Building Condition

-Jumber of Levels : 2

Year Built: 1956

Exterior Observations :

Operating warehouse

Interior Observations:

Organized operating warehouse

Fire Damage

Origin Level:

Orig in Area : Storage Area

General Condition : Occupied Good Building Construction : Protected Noncombustible

Fire Spread: Fire spread from southwest corner of building to the north and east destroying the warehouse portion of the building.

Structure Value : $50,000,000 Estimated Structura l Loss: $50,000 ,000.00 Content Value : $60,000,000 Estimated Content Loss: $60,000 ,000.00

Utility Systems

Heating System: Gas Heating Heat location: Multip le

Electrical Supply Entrance: North side Panel Location: Multiple

Panel Components : [o -; eakers -0 Fuses - -­

Supplemental Heaters: None located Supplemental Heat Location: NIA

Comments:

Protection Systems Sprinkler System: @

Activated : D Results :

Smoke Detectors :

Entry Alarm : 0 Activated : =:J

Alarm System Comments :

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Incident 15-80-000597 Narrative Investigator. Major G. Henry Ott

Date: Friday, April 03, 20 I 5 Narrative :

For the narative of this investigation , see the supplemental report dated July 24, 2015.

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William F. Bowman , Lt. Colonel Fire Marshal

Sir:

July 24, 2015

Re: Fire Investigation Locat ion: 4000 Buechel Bank Road

Date: 04/03/ 15 Time: 0651

Incident: 15-80-000597-90

The following documents and summari zes the investigation of the above captioned incident.

Initiati on

On Friday morning , April 3, 2015 MetroSafe. the unified dispatch system for the city of

Louisville. received a 911 phone call at 06:50:32 from Karen Elbert , an operations manager for Derby Industries at GE Appliance Park. She reported that there was a ''huge " fire in AP 6, which

is Building 6 of GE' s Appliance Park. Derby Industries util izes space as a warehouse that

supplies parts to General Electric. At 6:50:58 MetroSafe would receive a second call from Nathan Allen, another Derby employee , who would report a warehouse fire in Buildi ng 6.

MetroSafe would create ru1 incident for dispatch at 06:51 :21. At 06:58:0 I , a third call wou ld be

received by MetroSafe from GE Security , the on-site security force that self-monitors the

internal alarm system. That call would come eight minutes and fifty four seconds after the

security force received a water flow alarm on the system identified as P2-2635.

The location of the fire is mostly within the Okolona Fire Protection District. Their

predetermined dispatch policy is to start four engines to a report of a commercial structure fire.

As a result , the MetroSafe Computer Aided Dispatch (CAD) system recommended tl1e four

closest available staffed engine companies based on their A VL/GPS or if they were

recommendable , but the particular apparatus did not have A VL/GPS their actual station location s would be used . Those companies were two engines from the McMal1an Fire Department and one

engine each from the Jeffersontown ru1d Fern Creek Fire Departments. Major Jody Craig , the

on-duty operations commander for Okolona , would respond as the command offtcer from

Okolona and would assume the role of Incident Command er upon his arrival.

It should be noted that at the time of the incident , a large portion of the metropolitan area of

Louisville had suffered a significant rain incident with up to nine inches falling in portions of

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Jefferson County starting at 0234 hours. As a result, there were substantial flooding related

incidents reported in numerous areas. This included Okolona, Highview, and Buechel , all fire

districts that surround GE. (Regarding water related incidents , the Bu echel Fire Departm ent

responded to 14 incidents , Highview responded to 19 incidents , and Okolona responded to 65

incidents.)

At th e time of the incident , Okolona had four staffed companies on duty however all were out of

servic e. Unit 8032 was out of service on a water rescue, 8033 and 8051 were out of service on

water leaks, and 8053 was out of service on a gas leak.

At 06:58: 12, Unit 5502, a command officer (Am back) with the McMahan Fire Department

arrived on the scene six minutes and thirty nine seconds after the run was accepted by

MetroSafe. Maj or Craig would arrive at 06:58:55 . The first engine, UnH 5551 , arrived on the

scene at 06:59:07 .

McMahan companies responding on the west side of Building 6, reported hea vy smoke coming

from the southern end of the west side of the building and companies on the south side of the

building reported heavy fire in the west end of the warehouse. Major Craig would establish a

command post on the southern side of the building at 07:03:00 and using the incident command

sys tem assigned an Operations leader (Schmidt 7101 ), a Division I leader (Bay ens 1105) and a

Safety officer (Amback 5502). An interior attack using a 2 ½ inch handline through an open

overhead door was started but at 07:09:01 the building was evacuated by order of Major Ba yens

because of the fire conditions. At the same time , significant water supply issues were beginning

to pre sent themselves .

A second alann would be requested at 07:04:17 , a third alann at 07:07:39, and a fourth alarm at

07:23:01. At 07:45:53 Command wou ld request a fifth alarm.

As a result , at 07:49:52 Command would requ est a box alarm dispatch from the Louisville

Division of Fire that would be supplem ented by multiple extra pieces of equipment and

command officers as the incident continued.

EventuaJly the fire would be stopped at the eastern portion of the structure near the office area

and at the warehouse ann ex on the north side of the building. The fire would event ually be

controlled later that afternoon , with total extinguishment of hot spots completed four days later.

Multiple command officers reported that their strategy was to stop the spreading fire with master

streams at the south door where the init ial atta ck was made, with lines from the north at loading

dock 10, and from multiple locations at the east end the building.

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Investigative Request

While monitoring radio commun ications , the undersigned self-initiated and requested all on-duty Metro Arson Bureau members respond to the scene. Upon arrival, a quick briefing was held with Major Craig who reported that everyone was out of the bui I ding and the fire was heaviest just to the west inside an overhead door on the south side of the structure. Given the size of the incident Major Craig requested that an investigation be initiated. Eventually , all eight swom members of the Bureau in town would be on scene that day.

A systematic investigation began using the scientific method as a guideline. No preconceived

conclus ions as to the cause of the fire were drawn at that time.

Initial Scene Assessment

The undersigned initially completed a 365 degree tour of the building checking access, entrance and security of the building. It was determined that all of the exterior man doors were unlocked and accessible , which is a normal condition. Most semi loading dock doors were blocked with

trailers on the north and west sides, with the semi docks on the south side of the structure unblocked but the doors initially closed. (GE Security would open most of the semi doors on the south side before the electric overhead door openers lost power.) At the time of the undersigned arrival. the fire was heaviest in the southwest comer of the facility.

As other members of the Bureau anived they began documenting the conditions of the exterior of the building on all four sides of the structure . An interview team was established to interview and obtain statements from those persons that were in the building at the time of the fire. As other investigators responded to the scene, they were assigned tasks as needed.

An initial assessment of the structure as required by NFPA 921, revealed multiple safety concerns, the first being that it was multiple hours before the fire would be knocked down and then several days before all of the smoldering spots on the property were completely extinguished. Until the stability of the building could be detenn1ned, access to the structure was limited .

It was noted that the gas was turned off to the entire plant at the main station near AP33 and the electric for the structure isolated at the boiler house by General Electric personnel using the magnablast breakers on the distribution network. This occuJTed at approximately 0815.

At approximately 1000 hours on the day of the incident, a Facebook posting was identified that showed the fire in its very early stages. The LMPD (Louisville Metro Police Department) Real

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Crime Information Center was contacted and provided intelligence identifying the person responsible for the post. Eventually the actual person who took the photograph (Childress) was located and interviewed by investigators. (When she took the photograph , she was standing outside the repack area in the take cover hallway , looking south, down the aisle between row ABA and ABB.

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Within 24 hours , a Derby Industries employee provided a video (Allen) that showed the fire and

its location. The video appears to start in the aisle between ABC and ABO and then move to the

right to the aisle between ABB and ABC, where the view was very similar to the photograph that

had been obtained. At that time Mr. Allen was standing in the take cover hallway. A sketch

provided by Derby Industries to investigators , was used to place a possible area of origin and that

infonnation was used to assist the planning of suppression in activities extinguishing the

remaining fire.

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Based on that information , the portion of the building where the fire origina ted was identified as

the southwest corner of the structure.

The main scope and objective of the investigation was to determine the origin and cause of the

incident along with identifying the responsibility for the damages which occurred. (NFPA 921

1.1) Another scope of the investigation was to determine what fire prevention issues played a

role in the cause or contributed to the growth or extinguislunent of the fire. (NFPA 1730 8.7.52)

At the time of the initial incident , Major Craig reported that firefighters had experienced water supply problems , which played a sign ificant role in their inability to control and extinguish the

fire. Additionally they reported that the sprinkler system was not containing the fire when they

arrived.

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Because the fire continued to smolder in areas under structural collapse, as well in portions not

accessible by master streams, the undersigned authorized and coordinated heavy equipment in

making access paths into the structure from the south side to the center, and then in a westerly

direction to allow access by firefighters. Prior to that entry all sprinkler risers and mill water

loop supplies were identified and excavation was not allowed in those areas.

At approximately 1700 hours on the original day of the incident and from that point forward, the

unders igned was included in all joint incident command meetings , as well as providing

information regarding on scene security and access for the purposes of the investigation. The

Metro Arson Bureau maintained twenty four hour scene contro l while the Okolona Fire

Department provided suppression support until the conclusion of the scene investigation. Each

time membe rs of suppressio n entered the structure Arson Bureau members were consulted and

advised on the scope of their activitie s.

This same process was used regarding contractors on the scene who provided generators, food,

bathroom facilities, and lighting .

To prevent acces s from all other parties , a fence was erected around the north , east and west

sides of the property and doorways from the office portions of the building were secured closed

and locked. Within a day, the office portion at the east end of the property was returned to the

control of General Electric.

Given that the scene investigation lasted for several months , weather conditions were monitored

for the safety of the individuals processing the scene and adjustments made as needed. Additionally , mon itoring for contaminates was conducted multiple times a day and the

information readily supplied to investigators and other partie s who would enter the scene. At no

time oi1ce the interior scene exam was initiated did the level of contaminates exceed the daily

permissible exposure limits. Arson Bureau members flooded the interior of the building to assist

w ith the conta inment of the dust.

To support the investigative needs of all interested parties , a j oint exam was conducted of the

scene. Interested parties , upon notification and provision of basic information to GE legal

counsel , were allowed participation in the investigation. Prior to approval for team participation ,

each member was required to take a GE approved safety briefing and agree d to conduct

themselves in an appropriate manner. Investigat ive team members , both public and private . entered the property surrounding the structure via a security guard controlled access point and

attended daily morning briefings and evening briefings if needed. At those meetings ,

participants were asked if there were any complaints , which were resolved immediately.

An Arson Bureau commanding officer was present at the scene on all days where activities took

place to address the desires or wishes of aJI of the involved parties . Legal counsels for different

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parties were also granted the same access. The only parties denied access to the portion of the buildjng where the fire originated were claims adjusters not directly related to the origin and

cause of the incident. Instead, they were given private tours of the area where the bulk of the materials were stored.

On days when operations were conducted by the investigative team, a sign in sheet system was

used.

The only disputed area among the private investigators , mostJy fire protection engineers, was that of the Mill Water plant, and that was at the direction of GE. While an initial tour was conducted , and the Bureau allowed unlimited access, the Bureau had hoped to gain additional insight as to the Mill Water plant operations from fire protection engineers not directly related to

GE.

During the investigation , Bureau investigators provided general infonnation as it was developed to all of those present at the incident scene and set up a web based manner to share infonnation. Plans thought important to the investigator were uploaded early and then an extensive number of the written interviews were also provided. Initially the web site was going to be controUed by General Electric but to prevent any accusatio ns of bias; the Metro Arson Bureau maintained the website.

On June 18th, the property would be released by the Louisville Metro Arson Squad and the

Okolona Fire Department.

Property Description

Overall Plant

General Electric Appliance Park is a large industrial manufacturing complex that contains seven large structures with more than 30 other smaller structures that support the manufacturing of appliances . The complex occupies 87. 64 acres of land, and for the purposes of tax assessment, something General Electric pays close attention too, is assessed at 2.1 million for the land and 12.6 million for the improvement s for a total value of I 4. 7 million dollars for the entire complex.

Building s 1 thru 5 actually, or have, manufactured product and Building IO is for the storage of manufactured goods. Building 6, where the fire occurred~ is mainly used for the storage of parts that are received . sorted, and then moved into the first five buildings ; however. many parts are

shipped to other companies outside the plant that sell GE parts to repair their products. Other buildings important to the investigation were the Mill Water Plant (Building 23), the Boiler House (Building 20), the Executive offices (Bui lding 35) and the old fire department building (Building 28). lt was observed that an overhead conveyor system is in place that connects the major manufacturing buildings with Building 10. the warehouse.

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Construction for the property began in the early J 950 ' s, and the six main buildings on the

property are very similar in design and exterior appearance. Common to the six original large

buildings are two story office areas aJong the eastern side of each structure. When originally

constructed , the property was designed to be self-supporting contain ing a pumping station , water

treatment , power plant , rail yard, fire department , and security force.

A residential neighborhood commonly referred to as Buechel is located north of the plant.

Access to this area is along Buechel Bank Road. Located to the west of the property is another

residential neighborhood which was originaJJy known as Black Mudd but is now more

commonly referred to as Newburg. Access to the plant along the west side is yja Shepherdsville

Road. To the south of the property are sma11er commercial structures, situated aJong Poplar

Level Road. For the longest period of time, the eastern side of the plant was undeveloped;

how ever, GE sold some of the property that was developed as privately owned warehousing.

Just outside of the original property to the east are small neighborhoods and Mercy Academy , a

girl's Catholic High schoo l. (At the time of the fire school was out because it was Good Friday.)

A rail line enters the property from the south side and moves to a switching yard near the north center of the plant, which then feeds into different portions of the property including each of the

main manufacturing buildings .

In general , the area surrounding the plant is enclosed with an eight foot fence, with barbed wire

across the top. The majority of the people on the property park in a mile long parking lot on the

eastside of the plant outside the fenced area. From that location, people enter the secured area on

foot thru turnstiles. Truck traffic for the property enters along the north side off of Buechel Bank

Road at Gate 3, which is manned by security personnel. Other vehicles, including executives

who park close to the individual buildings , enter thru Gate 1, which is the offices of the security

force, located near the center of the eastside of the property. It is within these offices that

security monitors the alann systems, dispatches officers as needed, and processes visitors. It was

noted that portions of the fence had been damaged or openings were observed.

Also important to the investigation were gates on the property that are no longer operated on a

daily basis or manned by security .

Just south of the southeast comer of Building 6 is Gate 5. Officers were responding to this

location to open the gate ; however aniving firefighters would cut the Jocks off.

A second gate of importance was Gate 4 at the come r of Rangeland Road and Old

Shepherdsville Road . As the fire would burn and firefight ers were in search of a water supply

outside the plant, plans were made to lay a supply line west from the building of origin to this gate; however, they were abandoned because of the flooding over the roadway from the water

retention pond GE maintains .

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Building 6

The involved building sits at the southern end of the main row of buildings.

For the purposes of this investigation, the north side of Building 6 is just south of Building 5, the east end of the building fronts the main parking area, the south end of the building towards Poplar Level Road and the western side of the property faces towards Old Shepherdsville Road.

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===================6~00~ ~ers 200

1t was determined that General Electric uses a marking system based on columns used for the steel support system. The main steel forming the exterior wall running east to west on the south side of the building is considered column A. One hundred feet to the north is column B, continuing to column G which makes up the north wall of the building. Starting again in the southeast comer are the rows, with the first row running north to south labeled 1. Moving from east to west, marked in odd numbers were the rows continue to row 47. These east to west columns are 20 feet apart. This system was helpful in discussing items with GE, who used the

number system freely in conversations. At times, Derby would also use some of the same numbers to report water leaks within the building; however , Derby had their own number system.

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1n general, the building measures 600 feet north to south and 1000 feet east to west . A smaller

structure, called Building 6A (Annex) , sits to the north of the main building and measures 100

feet north to south and 520 feet east to west. In total , the building is reported to contain 700, 121

feet of space and is over two stories in height.

The building was constructed in four different phases . The original building , which was the

eastern half of the structure , was consfructed in 1956. In 1967 the westem half of the warehouse

was constructed , which started at the south side west overhead door at column A27. In 1965, the

eastern half of Building 6A was constructed and in 1968 the western half of Building 6A was added.

About one sixth of the property is occupied as the two story offices at the eastern end of the

building . With few exceptions , the rest of the structure is used as warehousing or related

operations , with a small portion dedicated to labs.

Along the eastern side of the structure, there is a set of doors which are the main pedestrian

entrance to the building. Employees and visitors park in the main parking area , walk thru the

turnstiles and enter thru these doors . Almost all Derby employees enter thru the doors, walk thru

the office area entering the warehouse , make a quick turn north and then west , and enter the

Derby access hallway /area. On the north and south end s of the two story office section are additional doorways that all provide access to the building and then stairwells that provide access

to the second floor of the offic e building .

Along the n011h side of the eastern end of the building are several man and overhead doors tha t

provide acces s into the warehouse porti on that was occupied by GE, including the Building 6

maintenance offices and a work shop for another GE business involving power solutions.

Becau se it suffered minor smoke damage , the entrances and exits of building 6A will not be

detailed; however, access into the building, allowed access into a walkrway running east and west

that was separated by fencing topped with razor wire along the north side of the Derby

warehouse space.

Along the western end of the north side of the structure was a set of IO semi loading docks and a

man door which were used as the receiving department for Derby. At the time of the fire, almost

all of U1e docks were occupied ; however , one truck was allowed to pull away as the fire burned .

West of dock # 10, was a man door that led into the unJoading dock area. Just to the west of this

doorway were the administrative offices for Derby .

In the center of the west ern side of the plant are two semi doors with a double wide sized doorway that entered what was described as a "take cover area·•. The doorway , large enough to

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allow entrance with a four wheeler , ran 250 feet west to east and consisted of concrete block walls with a poured second floor over top.

On the south end of the west side was another set of three semi docks and another man door.

This area made up the shipping depai1ment for Derby Industries .

On the south side of the structure was a small two story addition that contained an abandoned

railroad dock . Within this section was a large overhead door which is the location where the

initial attacks were attempted by firefighters. It is important to note that there was a large green

commercial dumpster with compactor located just west of the overhead door that would be

mentioned by many employees as a reference point. A man door was also present that allowed

access to a small second floor that contained a surplus of overhead lighting . The first floor

conta ined several outdoor cooking grills and damaged product.

Near the eastern end on the south side of the main bui !ding were three more loading docks as

well as an overhead door where an additional attack on the fire would be initiated.

It did not appear tha t there were any recent changes to the occupan cy usage , and the structure

size was consistent with measurements provided by PY A. For all practical pwposes, the building was unse cure at the time of the fire.

Building Systems and Ventilation

Originally , the warehouse portion of the building was used to manufacture room air conditioners .

At that time , a key component to the process was a Mill Water supply that was used for multiple

purposes , including cooling heavy machinery. Water for this activity is co1Iected from the roofs

and parking lots on the GE properiy and then drained to the Mill Water plant. At that point it is

stored in four large holding tanks , eacl1 holding 1,000,000 galJons. Pumps are in place that

returns this water to the different buildings.

As the manufacturing process developed and changed, there was no longer a need for the Mi]l

Water supply in the manufacturing process, but it was still needed to provide water for the plant

wide fire protection systems including hydrants , risers and sprinkler systems. The fire

suppress ion system serves the entire complex , including the six largest buildings , via

underground mains, which are aged. Plant personnel , truck drivers ai1d security personnel

reported that the underground mains fail five to six times a year.

The Mill Water system enters Building 6 at two different un-valved locations and completes a

loop around the interior of the entire warehouse portion of the Building. Because it is no longer

in use , plant officials believe that it was turned off at valves within the interior of the plant at

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ceiling level. Because of the age of some of the valves, there was leakage of some water into the internal piping, allowing them to fill with water.

A test of the MilJ Water hydrant system 13 days after the incident revealed that two hydrants could be opened before going below 20 PSI, the cutoff for use by a fire apparatus . It was also noticed that when water flowed from the hydrants , the audible alann did not sound in the Boiler House.

During interviews, it was also revealed that as the fire burned and the Boiler House/Mill Water plant operator responded to the Mi11 Water plant , the fisher valve was sti ll dumping water into the holding tanks , even though there was a great need for water to extingu ish the fire.

Domestic water is provided to the plant by the Louisville Water Company, mainly to be used for drinking and sanitary needs. It was detennine<l that the property contains approximately I 1-13 domestic supplied fire hydrants that surround the main buildings and warehouse. Neither the Louisville Water Company, nor the local fire districts, maintains the hydrants. Overall, the hydrants were found in poor conditions. The domestic hydrant on the south side of Building 6 was not used because it was found flowing water thru the cap and could not be turned off because the stern was broken. Firefighters could not tum it off to uncap and then use. The domestic hydrant on the north side of the plant was marked with an out of service tag.

Electrical power for the involved property 1s provided by the Boiler House (Building 20) .

From the Boiler house , a 13.8 KV line enters the buildfog at the southeast corner of Building 6A and then travels into Building 6, taking two routes as it feeds into the power vaults located on the roof of the building . When originally construc ted, there were eight vaults on top of the building; however several of them have been taken out of service.

The important feed for this investigation is the supply that feeds Vault 8, then Vault 7, then Vault 5, all above. the roof of the building. At this point , the supply moves under the roof as it exits

Vault 5 and runs in the area where the fire was originally discovered . At that point the circuit, wlule under roof, moves east to the southeast corner of the warehouse where it goes underground and feeds Building 35. (The second circuit that enters building 6 goes from Vault 4 to Vault 3, to Vault l and then Vault 2).

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Once inside the building the power is stepped down, starting within the vaults, thru a multitude of transformers, buss bars, and breaker panels as needed. Any attempts to analyze the conditions of the panels were fruitless as almost all of the interior components were consumed during the fire.

The only areas of the building that were air conditioned were the Derby Offices, the cleaning company offices and the eastern office section. Roof mounted units were noted for most of these different sections. The warehousing section was not air conditioned.

The only heat appliance important to this investigation was a very large gas fueled heate r located in the warehouse section on the south side just west of the overhead door (A-31 ). After the fire it remained undamaged but was important because many Derby employees used it as a visual reference. (The gas supply had been turned off a few weeks earlier as outdoor temperatures began to rise.)

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The building has a fire alann system that is contro lled by a Simplex system. Multiple Simplex

nodes are present; however, the main panel is located in the security force offices at Gate l . The

system controls multi ple sensing devices within the building including pu ll stations and water

flow alarm s. The initial rep ort of this incident was a water flow alarm on P2-26 35 at 0649 hours.

Fire extingu ishers were noted placed around the structure, and while a few were gathe red at the

beginning of the incide nt, none were discharged on the burning fire.

Of important note to the suppre ssion operation is a 12,000 gallon tank of Cyclopen tane which

was loca ted on the north east exterior of Building 6, between Building 5 and 6. This tank , if

exposed to fire. would have created an even more sign ificant, possible devastating event , and

was a key focus of firefighters at the time of the fire.

Building Occupancy

The building is owned and partially used by Genera] Electric.

The offic e area on the eastside of the build ing includes accou nts payable for this plant as we ll as

other plants in this region . (A portion of this function on the second floor center of the eastern

office area protrudes into the second floor area of the warehouse and had suffered significant

damage.) Another large function is the offices that direct and support the customer service

operations for General Elec tric worldwide. There were also several testing labs noted, including

one actually located in the warehouse portion of the building.

Within the warehouse, GE has a maintenance department in the northeast corner which was

noted early on in the investigation when a fuJI sized pickup was found outside the maintenan ce area, totally consumed by the fire. To the no,th of the maintenance department was a small area

which was used by another GE pa1tner that sold and maintained large electrical switchgear .

General Electric also had a fenced in section just inside the warehouse near the center main

doors. This area was called ''Stratosp here " and was used to rework part s. Just south of thi s area

was an area that was leased to Xerox that provided the major printing operations for the entire

park.

On the wes tern end of the building were two businesses that occup ied space. The first was the

Newbold Cleaning Compan y that supplied cleaning services for the entire plant. Their management offices could be entered along the hallway which ran across the western interi or

wall of the plant. To the east of the cleaning compan y operations was a room that was used by JJI, the company that provided mail services to the plant. Within this room, parts that are

returned by custome r service representatives , would be sorted and then returned to the particular

building where the item had been used in the manufacturing process.

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The rest of the space was used by Derby lndus tries. Their main on site management operations

were just to the west of the receiving department which is on the n011h side of the building at

F35. Small offices were also located in the southwest comer for the shipping departmen t along

the south wall at A45.

South of the take cove r area (03 7 to D47) was a large two story area, with a smaller area to the

east on the first floor known as the repack area. It was within this area that parts were managed

by Derby that either needed to be returned, or in some cases, minor changes or repairs made to

the construction of the part and it returned to the warehouse floor for future use. TI1e eastern

most part of this area was known as the pump room, and some of the doorways had been recently

been covered with Grainger noise absorbing material.

In the area of the C and D columns, between rows 23 and 27, Derby Industries operated a

maintenance department , which for the most part was fenced in. It appeared that the main focus

of the area was maintaining all of the forklifts and tow motors used in the day to day operations.

The area was also used for the storage oflight bulbs that Derby used within the faci lity. (At the

time of the fire there was no motorized equipment within the area of origin. and while there was

welding and cutting machines available in the maintenance area, no operations were talcing place

or had been undeiiaken in the area of origin.)

The final area oflmportance was the .. cage' ' area which is located on the south side center of the

building between A and B columns, between rows 15 and 19. It was in this area that a small

smoldering fire was discovered on March 3, 2015 .

Information (Data) Collection

Beginning at the time of arrival on the scene , and over the next two and a half months ,

information was gathered regarding the incident from observations and multiple sources both

inside and outside the plant.

Because the collapse of the building was affecting the fire suppression system regarding

Building 35, Gene ral Electric , under supervision, was allowed to cap four mill water lines and

two sprinkJer riser lines the weekend after the fire that could not be turned off. By capping the

lines , the fire protection system was allowed to build pressure for the rest of the plant and allow

it to be occupied and manufacturing restarted.

On Monday, April 6, 2015 entry was made into the building and multiple reconnaissance tours

were conducted to gather inforn1ation important to the investigation.

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One of the goals at this stage of the process was to detennine what role the front office portion of the building as well as the annex section possibly played in the incident. Initially, from time to time, GE personnel were allowed access to the building to remove critical information while

escorted. Once it was determined that there was no relationship to the origin and cause of the incident, those areas were returned to Genera l Electric about Wednesday April 8th with the understanding that the investigators joining the investigation at a later time would be able to access the buildings for documentation purposes .

For the remainder of the investigation, two operations continued; one to complete follow-up and conduct interviews , both on and off the property, and the other to complete an area of origin investigation . The debris examination was conducted in a planned and systematic manner, using layering to identify the availab le fuels and their fonns and the possible ignition sources within the area of origin. As is a standard operation of the Louisville Metro Arson Bureau, the investigation worked from the area of least damage to the area of greatest damage .

Exterior Exam

The exterior examination of the warehouse revealed that the outer walls along the south side consisted of four different types of exterior coating. The ground level covering was constructed of a brick facing. small paned windows ( 12' by 1 O'') in the center of the wall, metal siding for the next quarter of the wall and more window panes at the upper portions of the building. (Firefighters reported that they were able to watch the fire spread thru the building via the exterior windows.)

On the western side of the structure, the brick covering was in place; however. the majority of the rest of the structure was covered with metal sheeting. On the northern side, there was brick lower covering, small metal windows , and the metal sheeting for the upper half of the wall covering on the western portion of the north wall. On the eastern side of the north wall, there was the brick lower covering, small windows, metal sheeting, and small windows from about midpoint of the building to the east. The office portion of the building had a continuous row of windows for both the first and second floor within the brick covered walls.

The roof was flat and consisted of a layered system of foam, membrane and gravel.

A review of the exterior along with aerial photographs revealed that the heaviest amount of fire was in the westem third of the plant. When a comparison was made of the electrical vaults located on the roof of the buildings, vaults 5, 7 and 8 suffered the most damage and collapse. This observation was confinned by information from both employees and firefighters.

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While 8 semitrailers were located at the receiving docks (north Side), two were at the south side,

and four were at docks on the west side, their position did not affect the overa ll outcome of the

incident as they remained undamaged.

Overall, the exterior grounds were well maintained.

It should also be noted that once the fire department was able to establish a positiv e water supp ly

off site later in the incident , they were able to stop the spread of the fire as it moved from West to

east, and south to north.

It is important to note that the when the undersigned walked the entire exterior of the building , at

no time were any of the sprink ler gongs , wh ich number between 15 and 20, sounding.

Interview s of the first arriving companies con fumed the same informatjon in that the sprinkler

gongs were not sounding.

Also observed during the exterio r examination were the post indicator valves. especially those on

the south side of the building. Firefighters would report that when they arrived they believed the

PIV ' s were in the open position. The PTV valves would be orde red closed because of building

collapse , the lack of sprinkler performance. and water coming from the connections at floor level

along the south side of the building where collapse had occun-ed.

Because of the critica l damage. access for an examination of the roof could not be cond ucted for

safety reasons but both helicopters and drones were used to visually inspect the areas.

Interior Exam

Observations confirmed that the structure was used as a large parts supply distribution facility.

Both the shipping and receiving docks suffered minor damage and the products in eight semi

trailers located at the receiv ing dock on the north side of the facility were returned to Derby after

thorough documentation.

Prior to entry into the structure, Derby Lndustries was able to provide a diagram , that while very

general in natur e, provided a reasonably accurate layout of the interior of the Building .

Product entered and exited the building from two basic loading dock areas. There was limited

damage to the shipping area and it along with the associated offices were found organized and

free of trash. The on1y comp laint uncovered about trash was that some pallets and wrapping

from pallets was left in front of a security "c lock " area on the south side that security requested

be cleared. A GE maintenance man reported that extra pallets had once been stacked in front of

the furnace on the south side of the building but they were immediately removed at his request.

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Observations of what remained after the fire indicated a clean and organized operat ion by Derby

Industries. When questioned , the GE employee responsible for the relationship between General

Electric and Derb y provided that there were no issues with Derby and that he did not believe that

General Electric could take over the functio n and do i t as we11 as Derby was able to.

There were two types of storage within the building; bulk storage and rack mounted shelf

storage.

Bulk storage , which took up more space than that of the rack storage , amounted to a pallet with a

bulk contain er containing product located directl y on the floor. Those bulk container pallet s

were never stacked. and were responsible for the largest portion of the eastern half of the

warehouse. Examples of the storage would be plastic pellets. appliance doors, appliance

insula tion and full large pallets of small screws.

TI1e other manner of storage was steel metal rack shelving. The metal shelving were standard

warehouse rack shelving that stood anywhere from 16 feet tall to at least24 feet tall. Not all of

the end pieces were bolted to the floor via a base plate. The end pieces con taine d welded

vertical and diagonal braces for support.

The two vertical end pieces were joined together horizontally by use of a metal beam.

The box style beams had a lip at the interior of the face which would allow for the placement of

shelving panel that could have been wood, metal bars , or metal grids. The beam was attached by

the end pieces via two hooks that would engage the end of the beam with the end piece and then

screws attached that would lock the beams in place.

The racks were placed in rows, most ly north to south , with another row that would back up to the

first , with a distance of about eight to ten inches between each rack. A brace would then be

attached to stabilize the two units to each other. The next set ofracks was offset a dista nce

which would allow the easy use of a forklift , placing and retrieving the product.

Derby Industries had a standard numbering system for their shelving and as an example; th e fire

is believed to originate near ABC-115 / 1 J 8-8. Regarding the main racking system , in the

northwest comer , the first rack of shelves began and was labeled AAA. This set of shelves ran

from the north wall of the warehouse in a southerly directi on to a bulk storage area where this

section terminated. The next row , to the east was row AAB, the next AAC until the lettering

sequence got to AAZ . The next row after AAZ would be ABA which would continue in the

same pattern. The next row at that point woul d start at ACA and this sequence continued across

the warehouse to the eastern wall, in all areas where rack shelving was used.

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There were three basic interruptions, or breaks , in the row of racks. One was for those required

where a vertical structw·al support for the building roof was located. The second was for

walking and forklift travel , and the third for offices, bathrooms , or the Derby maintenance shop.

Along each row , there was a second number. Again , in the furthest northwest corner, the first set

of shelves at AAA was position 1. Just south of it was position 2. Both of these two positions

were located between each of the vertical end pieces and connect by the above ment ioned beam.

This numbering system would go to the south with a total number of positions of 120, which was

the southernmost position. In effec t, 120 pallets could be placed next to each other from the very

northern side of the warehouse and tenninated near the south end.

At each rack location , there were also four or five levels of product. These posi tions were

labeled as A , B, C, D, or E. Level A was directly on the floor. Level B was at about shoulder

level or five feet. While most of the plant only had level D product , late in the investigation it

was determined that there were Level E racks , taller than those in the area of origin located to the

east of the Derby maintenance area . In those cases, product within the racks was substant1ally

elevated from the ground. Because of the damage and loss of metal strength, the best

measurement placed the E racks at 26 feet or higher. Rema ins of some wiring harnesses were

found hanging from the top beams indicating that there was product on the top level of the E rack.

Product mo vement reveals that it is shipped to the warehouse from across the world, which is a

federal trade zone, and is delivered on the north side at the loading dock area. Rather than pay

the standard import tax, the parts are maintained within Derby's trade zon e warehouse until

actually needed on the assembly line. The part s are then moved out of the warehouse, and GE pays for the parts at a reduced tax rate.

Based on the eight trucks that were present at the time of the fire, the following are examples of

the produc t in general, which were found in all areas of the warehouse:

I) Some product arrived on wood pallets that were stack ed three pall ets high for a total of

about five and a half feet in height. All three of the pallets were manufactured with

wood. The three units wer e then banded together using plastic bands. On each of the

pallets were cardboard boxes , and the entire unit was wrapped in plast ic clear shrink

wrap. When one of the boxes was opened, 40 metal appliance doors were found, each

door wrapped in a protective skin. Each door was then separated from the others in the

box using a piece of cardboard.

2) Another wooden pallet contained IO relatively tl1in boxes stacked to a height of about

five feet. The ent ire pallet was wrapped in shrink wrap. Each of the ten boxes contained

13 smaller boxes that conta ined plastic and metal parts that were all wrapped in a plastic

bag.

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3) A wood pallet contained stacked small cardboard boxes wrapped in plastic with the pallet capped in a cardboard top with the boxes being lidless containing rail upper rack assembly with plastic and foam protection.

The following is an example of the material stored in the building:

While the entire structure was destroyed and most of the combustible materials within it consumed , the overall housekeeping within the warehouse appeared good. This was based on the original photograph and video, observations in the shipping area which suffered Jess damage , and several reports from GE, Derby , and Factory Mutual employees. The only area not reflecting this was the exterior two story section on the south side where the initial fire attack was made. It appeared damaged containers had been haphazardly placed in the storage area of the building.

A search of the maintenance area revealed the same condit ions. Tools appeared to be stored normally, with no accumulation of broken or what appeared to be scrapped items. A large amount oflight bulbs were noted stored in an organized fashion within the maintenance area. Organized paperwork and extensive maintenance records were found concerning the Derby operations with the majority of them dealing with forklifts and other lifting equipment. (It was noted that in one case lights had been knocked off of the top of the forklift , but repaired.)

Once accessed , the receiving area was laid out as described by the workers. The construction and positioning of the rows ofracking were consistent and confirmed the statements that workers gave concerning where the fire was first observed.

Again all information gathered , based on Derby employees , firefighters , GE employees and the undersigned , coupled with the video and still photograph , the area of origin for the fire was in

between row ABA and ABO on the south side of the warehouse.

Based on observations in the area , the rack system was consistent with the rest of the building.

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At colwnn B-33 , there was a gap between the end pieces of the racks and the vertical structure

column. Much to do was made about the possible accumulation of trash in this area resulting in

an accumula tion of a fuel that could be ignited by a person careless ly smoking a cigarette.

Because of the amount of damage , but after a very detailed search, no remains of cigarette,

cigarette lighter or cigarette packagjng were found.

A description of the excavation process is as follows, and summarizes the normal day to day

operations.

Some of the most qualified or igin and cause invest igators, many with natio nal reputations, hired

by their respective clients , parti cipated in the excavation. Initia lly, fire protection engineers had

studied and documented the sprinkler conditions but only for a very short period of time. A grid

system was created which allowed for the areas to be broke down into smaller areas. and even smaller in the event that a key piece of evidence was located such as a lightbulb. Nom1ally, two

seasoned investigators would hand sift using small handheld trowels, shovels and rakes sifting the material which would then be placed in a container marked for the specific grid.

Docwnentation was extremely detailed by all parties. Important identified pieces were collected

and marked with an individual evidence number by a common scribe. If a specific item involved

lighting. one of the country's leading experts on lighting would excavate the area surrounding it.

The above container wou ld then be moved to a sifting location where two to four investigators

would sift the material over screen and containers. Additional important items not identified by

the first line excavators ( or all of the other parties who were observing the sift ing), was collect as

evidence based on the grid.

Running vertically, at the underside of the roofs edge. north to south, was the 13.8 KV electrical

high voltage cable supply for Building 35. It was noted to have suffered critical damage and

arcing along numerous locations in its path.

A large thick multi strand data cable which moved towards Building 35 was found in the area.

In the very early stages of the investigation , because of its importance as the main fuel source for

the fire, Derby Industries provided a product list, initially of the area where the fire originated

and then for the entire warehouse . As part of follow-up, ten random locations were chosen in

four different areas of the plant , involving the rack storage and the debris foW1d compared to inventory listing. In all incidents , the remains of the debris appeared to be the items listed .

Derby auditors believed the company had a 99% accuracy concerning the location of the pallet

on the shelves, with the on ly differences occurri ng when multiple boxes made up the specific

pallet which had been partially picked during the supply operations.

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Excavation along the west side of the ABB aisle revealed the remains of a round garbage style

container. A review of the rema ins withjn the can appeared unr emar kabl e, but it was collected as a piece of eyjdence in its entirety.

Of importance to the investigation is wea ther. It was severe just before the fire, and a substantial

amount of rain had fallen. Located at column B33 was a drain pipe whi ch drained water from

the roof to underground. Derby emp loyees would identif y multiple locations where water was

discovered at the floor level as a result ofleaks in the roof, and some explained the water on the

day of the fire as the wor st ever.

Excruciating detail was paid to the lighting within the warehouse , spec ifically in the rows where

the incident was detennined to have originated. Running overhea d north to south, in the driving

area, between row ABA and ABB was the conduit which suppli ed power to the overhead fixtures. Th e fixtures, which were arc tube in nature, were visible within the origina l photograph

and video, and appeared partia lly operat ional at the time of the incident.

While all of the fixtures in the area of origi n were located, identified , excavated, and collected,

those actually containing bulb s were examined and the bulbs themselves, where present, were

elimjn ated as the cause of the incident because the arc tubes were found intact. At this point in

the investig atfon, the ligh t bulb housin g and the wiring supplying them, while collected, was not

closely examined, and therefore canno t be eliminated as to the igrution source.

Based on the amo unt of burning in a specific location of the ABB row , including damage to the

concrete floor, samp les were collected and analyzed for the presence of a flammable liquid with

the results being negative.

While a 5 gallon blue kerosene conta iner was fow1d lying on its side in the shippin g area near the

offices , light smoke stains and a protective pattern was visible on the top of a utility cab inet next

to it. The container was old and dirty and appeared to have been knocked off the cabinet during firefigh ting master stream operations from the cabinet which was used to store other flammable

liquids and clean ing fluids.

The HVAC system, control units, supplemental heaters , and water heaters were not located in the

area of origi n and when found at other locations , failed to reveal any failures responsible for the

cause of the ind dent.

Alarm System

Based on a review of the Simplex system , the very first indication of a problem was a signal

received from the water flow switch at P2-2635 which covers the area where the fire was initially

seen by the witnesses.

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Witness information

Extensive interviews were conducte d with both GE and Derby employees as well as others

related to the operations of the building . Witnesses outside the plan1 were identified , located and

interviewed and some persons chose to contact the Metro Arson Bureau on their own accord.

Those interviews are documented either as written reports , or in some cases taped statements

which, for the most part , hav e been transcribed and added to this investigation. The following is

a genera l summary of the infotmation gathered.

The fire was firs1 observed by an employee (Eagan) while he worked on the receivi ng dock on

the north side of the plant. He radioed the location of the fire as the ABC aisle on the internal

radio system that Derby maintained for communications of the employees.

Many Derby employees report the fire at the B or higher level on the shelves, some as high as 20

feet in the ajr when first noticed.

Prod uct was being moved shortly before the fire because of the nun that had leaked into the

building from the eveni ng before. fn some instance s, tarps had been in place as a part of nonnaJ

operations for some period of time . Derby would report roof leaking problems to General

Electric at least twice a year. (Google earth images of the property on 09/22/14 would show

what appears to be patches and stains on top of the patches around the electrical vault directly

above the area of origin.)

None of the employees believed that the fire was incendiary in nature. The only recently

tenninated employee had lost his access to the plant and whil e he was upset that he had been let

go, he spoke of no motive to set the fire . A check of Genera1 Electric access system records

showed that his access card had been deactivated on April 1st at 0953.

Nathan Allen , Jimmelle Cannon, Rebecca Cravens, Jason Cun)', Karen Elbert, Todd

Farringham , Ted Fox , Ken Lasley, Brenda Pierce , Fernando Rodriguez , Ronnie Wa lker Robert

White, and Billie Williams did not observe the sprinkler system flowing when they first observed

the fire. There was no belief by the involved investigators that their statements were planned, or

rehearsed.

Jim Este s saw sprinklers working over the fLre, but they were not effectiv e and water was not

hitting the floor.

Jacob Fuller reported sprinklers working above the fire when he entered the structure as the last

of the Derby warehouse employees were evacuating. He repo1ied there was a stonn at the time

of the fire that was very significant and light n ing was in the air around the time of the fire .

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Debbie Brooks and Mike Christianson observed the sprinklers but outside the area of origin

based on their column and row identifi cation . Christianson may have seen water flow above the

fire but was more fami liar with the spri nk ler head that discha rged above his head.

Very few people ever heard an audible alarm once the incident began , and a few onJy heard

audible alann sounds late in the incident. Severa l people reported pulling the alarms and nothing

happening. It was also determined that several were in the building in the east office area and

did not know of the fire unt il other employees, not allowed to enter the turnst iles by security ,

called them by phone. Others only left the build ing because fire trucks were arriving on the

scene.

Cigarette smoking is very rare in the building as GE 's policy is that no smoking is allowed on the

property and there has been a focused effort since the smoldering fire in March.

The domestic water hydrant on the so uth side of the building has been leaking since last fall and

the one on the north side had been out of service for some time.

An unstable citizen contacted the Bureau offices and reported that small meth ghosts were

responsible for the frre. A nud e man found in a truck leaving the scene as the fire burned was

identified , interviewed an elimi nated as a focu s of the investigation .

Analyze the Data

At this point , based on the above observations, the degree of damage, observations made by witnesses and firefighters upon arrival, and the trnining , knowledge , experience and expert ise of

the undersigned , it is the opinion of the undersigned that the fire originated in the ABB and ABC

racks between locations I 15 and 118.

1n nonnal cases the type, style and fonn of the fuel load present would provide patterns which

would exhib it smoke , heat and flame indicators which wou ld identify the point of origin. These

do not exist in this case because of the size and complete destruction of this fire. While

ventilation is always important to the movement and the intensity of the fire , the fue l load had

the greater effect. The spread of the fire is well documented by the helmet camera worn by the

first firefighter who laid a two and a half inch line in the soutJ, (west side) overhead door , a line

which was ineff ective. At that time the fire was limited to about the southern end of about eight

racks of shelving and the south overhead doors provides easy access to the fire.

Electrical wiring ran thru the area of origin and was found on colwnn B-33 during the

excavation. All of it was collected; however, a detailed exam was not conducted by those

present. The wiring did not appear to be improperly sized, but no further determinations were

made because of the wide spread melting, arcing, and metal loss.

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Developing a working origin hypothesis

Using observations (Emp irical Data), witness information , limited pattern identification, initial scene assessment and analyzing the information gathered , the following working hypothesis were developed.

I) Careless Smoking

On March 3, 2015, a smoldering fire was discovered involving insulation inside of a box in the ' ·Cage" area. There was no flaming combustion. Also found in that box was the exterior wrapper of a pack of cigarettes and a cigarette butt. In the opinion of Derby employees , the cause of the fire was believed to have been the result of careless smoking , and the conditions at the time tend to indicate that. A strong management response was immediately initiated by Derby with an all hands emp loyee meeting with everyone advised they would be terminated if caught smoking in the building. Every Derby emp loyee , as well as some outs ide Derby i was aware of the policy and its serious nature .

However, in this incident, the conditions are significantly different.

At the tim e of the fire, only a very few people had been in the building for a short period of time and starting their activities wh ich were either planning tasks in the office or removing product exposed to rain water comi ng from the roof. Employees had not been on site enough time to take a rooming break.

When tbe building is occupied and in full operation , the ABA/AB B aisle is a highly traveled area and a direct connection between the administration offices , shipping and receiving . It is not an area where one would concea l themselves in an attempt "to sneak a smoke ". On the other hand , the ·'caged" area is a remote location , not on any direct aisle way and a place where someone could conceal themselves.

Regarding the pocket that is created at the colwnn and the possible accumulation of debris that could commonly be ignited by a dropped cigarette on the floor , this is not consistent with the scene for several reasons. The first is that every witness on the scene and the video and still photograph identifies the ear1y location of the fire multiple feet off the ground. Overall, the cleanliness, even based on observations of outside risk manager engineers , was good. Again, the other reason is the time span.

(For a comparison , the Camp Taylor Fire Protection District was contacted which has the inspection authority for the property at the Derby Headquarters on Robards Lane. The last inspections by the fire department in 2010, 20 I 2 and 2013 failed to revea l any trash accumulation problems.)

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And finaJly, one must consider the overwhelming amount and condition of the fuel in the area of origin. Dropping a cigarette on top of a cardboard box that is designed to contain, organize , protect , and ship product across the world and expect an ignition is unrealistic.

2) Light Bulb Arc Failure

Of great concern to all of the parties present was the possibility that an arc tube in a Metal Halide light fixture had failed and dropped super-heated smoldering metaJ on top of a rack which caused an ignition. Examination revealed that either the bulbs were not in place or they were found intact, eliminating the bulbs but not the fixtures.

It was noted that Derby Industries had purchased light bulbs on March 6th and 19111 from S and J Lighting but it was not known if they were installed.

3) Intentionally Set fire

Equally considered at the beginning of this investigation was the possibility that this was a set fire.

Quickly , investigators gathered the identification of any personnel that were on property when the fire originated. When the list provid ed by security included many other individuals, the scope of the intervi ews was expanded.

Background checks of the employees that entered the gates at the southern end of plant entrances were conducted which did not reveal any significant arrest, none of a vio lent nature and none with a fire setting backgrow1d. Management did not report any labor unrest and the only person recently discharged was approached and had no motive or grudge against the company. All in all the Derby employees held no ill will to their employer.

Most importantly , tbe scene exam faj]ed to reveal any evidence in the area of origin that indicated that the fire was set. The video and still photo also indicate that the fire originat ing well off of the ground, in an open area where there is considerable traffic , not the location of a traditionally set fire .

A review of the security logs for the period just before the incident failed to identify anything remarkable . There were two previous fires on the property, one involving an ambulance engine compartment on January 29 , 2015 in front of Building 28 and the other a dryer in the executive offices building (35) on March 19, 2015.

As with large scale incidents two unusual reports were received. The first was that the CEO of General Electric set the fire in collusion with companies such as Bechtel and Safeway. The second was that melh lab ghost living in the trees outside the building set the fire. Both of these reports were fow1d uncredible.

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There were no indications that there were separated and unrelated fue locations on the property and as mentioned above, the area of origin is not a concealed area, but that of a well-traveled area where it would be easier to be discovered. The lack of a pattern of similar fires occurring at other locations within the plant , also limits the possibility of a set fire.

Given the positive opinion and status of their job s, there was no reason to suspect that Derby employees had a revenge or retaliation motive. They, like every employee on the GE property. were aware of the sale of the General Electric to Electrolux , and were focused on presenting efficient, effective, and organized operations.

At no time did any GE or Derby employee rep01t to the Metro Arson Bureau any suspicions that the fire was set, or a specific person identified as a possible suspect.

4) Lightning

Based on weather data collected at Louisvi lle International airport , a review shows that significant wind and rain events started on Thursd ay morning and continued until the fire at 0651 hours on Friday. Total rainfall for Thursday April 2nd was 1. 17 inches and on Friday , a total of

5.64 inches of rain would fall. The National Weather semce would publish a data map for total precipit ation showing between 8 and 9 inches for the tv,o day period in the area near GE. A significant increase in the wind on the day of the fire would begin at 0530 hours, with some wind gust reaching 35 MPH.

Several different StrikeNet lightning strike reports would be reviewed. The data was provided to the National Weather service that plotted the data for investigators showing strikes of -18kA volts in the parking lot of Building 6 and a J 9.2 k.A strike in the rear of Building 3.

Video tape was obtained from FedEx which appears to show lightning in the area between 0632 and 0646, but does not definitively show any air to ground strikes. Video tape from the Ingram Company appears to show some flashes in the air, however the camera is pointing at the ground and is not raised towards the building until a few minutes before the fire. Attempts to obtain video from Gilt were unsuccessful.

An employee at Lacross Industries (Hicks) would observe what he thought was a lightning strike to Building 6 at about 0653 hours. When provided photograph s of the building , he circled the area where he believed the strikes to have occurred and sparks were seen. Those selections were directly above the area of origin as determined by investigators. A security guard (Bratcher) on the east side of the plant at Gilt industries saw a large flash just before the fire.

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5) Rain

Prior to the fire occurring, Derby had reported water leaks in the following areas, which are considered important because while these Jisted locations are where the water was found, they might not clirectly refl ect the location of the actual leak. Those locations were

Po le B36 Behind the repack room B39

Along back wall by shipping by pole 37 ABB-I 07 and I 08 by pole B33

In the middle of aisle ABD-90-A

A review of Google Earth shows what appear to be water stains on the roof, at the south end of Vault 5 which is clirectly over the area of origin. It also appears that a problem had occurred at this area as there is evidence of patches made to the roof. While General Electric provided a study of the area, it appears that the Google Earth image of 09/22/14 is accurate. Given the amount ofrain that fell that day, witness statements, and observations, it confinns that water was leaking into multiple locations within the warehouse.

6) Electric Arc

In the process of identify ing ignition sources in the area, electrical wiring was identified moving thru the area of origin , including that of the 13.8KV supply for building 35. As the scene was excavated, evidence of electric sho 1is was found , aJong with mu]t ipJe examples of melted conductors. These items were collected as evidence as the exam was completed and stored for future study.

AdditionaJ hypothesis were considered ; howe ver, they were eliminated as observation showed the ignition sources were either not in the area of origin and showed no indications of failure . These included forklifts, forklift charging stations, wrapping machines , vending mac hines , food microwaves and office equipment.

A key step in the investigation is the determination of how safety devices may have failed and how acts or omissions of both internal and external parties had an effect on how the fire originated and spread.

General Electric, who is insured by Factory Mutual , under goes a yearly inspection by an engineer who identifies areas where improvements can be made to protective systems. The result s of those inspections are prov ided to General Electric and then forwarded to Factory Mutual underwriters who make decisions about coverage and insurance rates.

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Factory Mutual has for 14 years, recommended that GE change and upgrade their Mill Water operation from a manual system to an automatic system and that new pumps and water mains be installed. The engineer predicted that if an incident occurred , there wou ld be approx imately one minute for additional pumps to be brought on line, or Building 6 would be destroyed by fire.

At the time of the fire, the four west pumps were out of service because of ongoing upgrades , which are part of a five year project. GE reported that they were six months into the project , with the Mill Water plant the first area of focus . (Work had been scheduled on the very rooming of the fire, but was canceled earlier in the week .)

In this case , an a1ann on the sprinkler system occurred and it was 19 minutes and 54 seconds before security would attempt to ca11 the operator at the Boiler House to have the pressure increased. There would be no answer at the Boiler House. Some 38 minutes and 34 seconds later, security would, for a second time , go to the Boile1· House and then escort the Boiler House operator to the Mill Water house . Once at the Mill Water house there were failures of three of the four remaining pumps.

It should also be noted that during sprinkler inspections on 11/6/2013 and 12/2/14 , a report generated by Midwest Sprinkler made note of the following:

1) The water gongs and motors test were satisfactory 2) (2014) That sprinkler heads were past their accepted age and require testing 3) (2014) All of the involved valves were not opened and closed 4) The height of stotage required a reevaluation of the sprinkler system 5) (2013/2014) Incorrectly reported that the occupancy hazard was the same as it was when

installed 6) (2013) that the hazards are not adequately protected

While a few people saw sprinklers in areas outside the origin or after the fire had burned to an

area outside the involved riser , there are an overwhelming number of people who report that the sprinkle rs were not flowing above the fire at the area of origin. Those include Karen Elbert

(multiple areas of taped statement 04/03/ 15) and Nathan Allen (taped statement a few days after

the incident and on 05/06/ I 5). Mr. Christianson thought he saw sprinklers above the fire, but

was at another riser when a sprinkler flowed above him. Jim Estes , another security officer

could not see if sprinklers flowed above the fire .

(After the fire, the Bureau would investigate a fire in a large sprinkled warehouse contai ning

palletized recycled paper and a shredding operation. That three alarm fire would be held in

check by the sprinkl er system and then extinguished by multiple lines laid on three sides of the building from an adequate domestic water supply.)

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A review of Louisville Water company maps reve aled that a significant amount of water is present outside multiple locations of the plant, with the greatest water supply on the west side of the plant.

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Louisville Gas and Electric (LG&E) was contacted and provided that there was no interruption of power to the plant as a result of the storm.

An evaluation of the fire suppression command and operations revealed an aggressive attempt to extinguish the fire with an interior attack which was thwarted by the lack of any positive water. It was only after companies were able to lay supply lines outside of the plant, some at distances greater than 5800 feet, were they able to stop the fire at the eastern end of the building.

In the end the fire would cause in excess of 50 million dollars in damages to the structure (GE estimate), and 50 to 60 million dollars in damage to product.

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At the time that the General Electric plant was constru cted, it was given self-inspection status from the State Fire Marshal 's Office. Under thi s status, General Electric would serve as their own fire protection authority , and in fact had the ir own certified, state recognized, fire department. There are apparently three other manufacturing operations in Metro Louisville (2 Ford plants and UPS) that have this same status.

Originall y the Black Mudd Fire Department , later transferred to the Okolona Fire Department at the time of their merger , would have response obligations but did not complete normal fire prevention inspections of the property. The only time that the State Fire Marshal would be active on the property was regarding hazardous materials .

Start ing in March of 2002, the suppression response mis sion of the General Electric Fire Department was dismantled. lnspect:ion and code issues were transferred to the other maintenance sections of the company, and the local fire districts became the main responders to fire incidents on the property.

There was never a yearly inspection of the property by a local or state government fire related agency. The Kentucky State Fire Marshal reported that during his tenure, he has never heard of the "Self Inspection Status". TI1e only substitution for local fire prevention inspection was the Factory Mutual yearly evaluation.

(A check of permits obtained from Metro Louisville Inspe ctions Permits and Licenses revealed that the overwhelming number of them were for asbestos abatement.)

Testing the Original Hypothesis

While the search of the area of origin was extremely detailed , the size and spread of the fire subsequen tly oblitera ted important pieces that would nonnally allow for the determination of the final cause.

Electrical failures and lightning strikes are competent ignition sources. A significant storm occurred just prior to the fire at which time lightning was observed in the area . Significant rain fell which from the accounts of many witnesses had entered the structure at multiple location s.

Using deductive reasoning the possibility exists of an electrical failure or possibly lightning in the area of origin . Either of these two poss ible theories could have led to the conditi ons that are seen in the first photograph and video of the scene. The fire grew as it would be expected , and spread as it did which was consistent with the observations made by the undersigned . The time line of even ts explains why this occurred.

Previous experiments and research has shown that an electrical failure, including the result s of those caused by the incursion of water onto the conductors, and lightning can be a competent ignition source.

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Final Conclusion

After an extensive and labor intensive investigation as summarized above, the area of origin was detenni ned. Other alternate areas were considered and eliminated. It is imposs ible to ignore the photograph and video although multiple interpretations from several enhancements resulted in different opinions as to what is observed.

After examination and interpretation of each component of data and while some of the possible causes can be eliminated, some cannot , those being an electrical failure or a lightning strike. While additional examihation of the evidence might occur in the future , without auy infonn ation that might be gleamed from those examinations , the cause shall be listed as undetermined as required byNFPA 921.

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Date Time

10/29/2012 21:52:00

4/29/2014 4:53:00

4/29/2014 22:14:00

1/29/2015 14:32:00

3/3/2015 0:00:00

Time from water flow

Time From FD Arrival

Description

Small fire at ceiling Building 5, southwest corner

Indications of Smoldering Fire, Could not locate. Fire watch established . Odor was in compute r room

Fire around oven

Ambulance Fire

Building 6 at B-21: Crate smoldering Cigarette Fire

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3/18/2015 12:22:46 Water flow alarm at 2635 P2

3/19/2015 0:00:00 Fire involv ing Dryer at AP 35

4/3/2015 6:45:00 GE security shift meeting

4/ 3/2015 6:49:07 Water Flow alarm 2635 Waterfl ow P2

4/3/2015 6:50:32 0:01:25 Karen Elbert with Derby calls 911 by telephone after seeing fire

4/3/2015 6:50:58 0:01:51 Nathan Allen with Derby calls 911 by telephone after seeing the fire

4/ 3/ 2015 6:51:21 0:02:14 Photo taken by Derby Employee Laura Childress

4/3/2015 6:51:21 0:02:14 Fire Department in time

4/3/2015 6:51:42 0:02 :35 Nathan Allen phone call with 911 ends

4/3/2015 6:51:43 0:02:36 Nathan Allen calls GE security by telephone and report s fire to them

4/3/2015 6:52:05 0:02:58 B column Speaker wire running east to west shorts/opens

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4/3/2015 6:52:21 0:03:14 Karen Elbert 911 te lephone call ends

4/3/2 015 6:53:19 0:04:12 Pull St at ion 2621 acti vated on first floor of off ice area

4/3/2015 6:53:35 0:04:28 Video taken inside bui lding by Nathan Allen (Derby)

4/3/2015 6:55:38 0:06:31 Susie Wick from Derby calls GE Security

4/3/2015 6:56:40 0:07:33 GE Security dispatched to Building 6 on a structure fire

4/3/2015 6:57:33 0:08:26 GE Security Brooks te lls radio to call 911 based on smell

4/ 3/20 15 6:58:01 0:08:54 GE Security calls 911

4/3/2015 6:58:12 0:09:05 McMahan command officers on scene

4/3/2015 6:58:55 0:09:48 0:00:43 Okolona 8006 arrives on scene

4/3/2015 7:00:00 0:10:53 0:01:48 Heavy Smoke, south side according to Park Federal Bank

4/3/2015 7:00:18 0:11:11 0:02:06 GE Security (Fuller) takes photo from west side

4/3/20 15 7:02:52 0:13:45 0:04:40 Heavy Smoke showi ng west end of building

4/3/2015 7:03:46 0:14:39 0:05:34 Heavy Fire showing inside overhead door

4/3/2015 7:04:17 0:15:10 0:06:05 Second Alarm Requested

4/3/2015 7:05:40 0:16:33 0:07:28 Security officer Brooks tells radio by radio to call the Boiler House

4/3/2015 7:06:00 0: 16:53 0:07:48 Electric Clock in AP 35 stops

4/3/2015 7:07:39 0:18:32 0:09:27 Third Alarm Requested

4/3/2015 7:08:00 0:18:53 0:09:48 Electric Clock in AP 35 stops

4/3/2015 7:09:00 0:19:53 0:10:48 Tony French calls Bibbs cell phone.

4/ 3/2015 7:09:01 0:19:54 0:10:49 Security advises no one answers the phone at Boiler House

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4/3/2015 7:09:01 0:19:54 0:10:49 1105 evacuates firefighters from the building

4/ 3/2015 7:10:00 0:20:53 0:11:48 Bibb calls Jeff Pendleton, his superviso r, call last 40 seconds

4/3/2015 7:12:00 0:22:53 0:13:4 8 Bibb calls Tony French, Call last 25 seconds

4/3/2015 7:13:10 0:24:03 0:24:03 Michelle Salles meets Bibb, he is doing what he can

4/3/2015 7:16:48 0:27:41 0:18: 36 Request to command to have Millwater pressure raised

4/ 3/2015 7:18:51 0:29:44 0:20:39 Building Collapse

4/3 /2015 7:19:40 0:30:33 0:21:2 8 Not enough water, have to go outside property

4/3 /2015 7:24:00 0:34:53 0:25:48 Tony French calls Bibb. Call last 26 seconds

4/3/2015 7:24:08 0:35:01 0:25:56 Fuller is sent to the Boiler House

4/ 3/2015 7:26:00 0:36:53 0:27:48 Tony French t akes photo at Shepardsvil le and Fern Valley

4/3/ 2015 7:26:00 0:36:53 0:27:48 Bibb calls Jeff Pendleton. Call last 1:21

4/3/2015 7:27:41 0:38:34 0:29:29 Fuller leaving Boiler House on way to Mill Water

4/ 3/2015 7:31 :00 0:41:53 0:32: 48 Bibb calls Jeff Pendleton. Call last 1:30

4/3/2 015 7:34:00 0:44:53 0:35 :48 Bill calls Jeff Pendlet on. Call last 27 seconds

4/3/2015 7:36:00 0:46:53 0:37:48 Fuller reports mill water done all they can do .

4/ 3/ 2015 7:40:00 0:50:53 0:41:4 8 Rick Urschel calls Bibb. Call last 2:31

4/3/2015 7:44:00 0:54:53 0:45:48 Rick Urschel calls Bibb. Call last 23 seconds

4/3/2015 7:46:00 0:56 :53 0:47:48 Bibb calls Rick Urschel. Call last zero seconds

4/3/2015 7:46:00 0:56:53 0:47:48 Bibb calls Rick Urschel. Calls last four seconds

4/3/ 2015 7:47:00 0:57:53 0:48:48 Bibb calls Rick Urschel. Call last zero seconds

4/3/ 2015 7:47:00 0:57:53 0:48 :48 Bibb calls Rick Urschel. Call last four seconds

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4/3/2015 7:47:00 0:57:53 0:48:48 Bibb calls Rick Urschel. Call last three seconds.

4/3/2015 7:48:36 0:59:29 0:50:24 No 5th alarm companies, dispatched PRP

4/3/2015 7:53:23 1:04:16 0:55:11 Director of GE Safety wants Building 5 evacuated

4/3/2015 8:20:14 1:31:07 1:22:02 Order given to evacuate Building 10

4/3/2015 8:12:28 1:23:21 1:14:16 Louisville Water Requested to Command Post

4/3/2015 8:31:02 1:41:55 1:32:50 LFD request additional equipment eventually totaling 13 apparatus and 8 command officers

4/3/2015 8:45:10 1:56:03 1:46:58 Manhole cover blown

4/3/2015 9:10:19 6:49:07 2:12:07 Fuel Truck on scene

Updated 07 /19/15 at 1500 Hours

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